By Kerry Allen

During his visit to the University of Birmingham this October, Professor Jeffrey Braithwaite asked his audience to consider why, given the policy emphasis on reducing harm, gains in safety have been limited in practice. His analysis presents three concepts for the development of safer health care systems:

1.Work-as-Imagined Vs Work-as-Done

2.Complex Adaptive Systems (CAS)

3.Safety I and Safety II

All three offer insight about where we have gone wrong on safety historically, but explanatory theories alone are unlikely to change practice. A shared vision of the solutions is often presented as an essential lever for systemic change.

This particular vision may be difficult to form. Statistically we can evidence harm prevention, but pin-pointing exactly when an adverse event didn’t happen and knowing why it didn’t happen is an altogether trickier science. The long term challenge is to make real examples of how harm has been avoided visible and understood.

Braithwaite’s recent publication showcases real world successes from 60 Countries, taking us from Brazilian knowledge management for quality improvement, to advancing Malaysian maternal health care, via Swiss breakthrough collaboratives for safe surgery and adverse drug event prevention.

So how powerful might the three concepts be for safety outcomes and what do they look like in the day-to-day work of health care leadership?

Braithwaite envisages health care systems as having a blunt and a sharp end. The sharp end is the frontline workforce, the blunt end are those who aim to influence healthcare, but do not deliver it e.g. policy-makers, executives, managers, legislators, governments, boards of directors, software designers, regulators, trainers, researchers. Those at the blunt end  carry out their roles with a mostly imagined and over-simplified idea of health care work. Braithwaite identifies some of the most common misconceptions of those who imagine work, observing that multidisciplinary team work is overstated and clinical pathways are imagined as more linear than in reality.

His call to action was that those at the blunt end must make more effort to understand how work is actually done. Those at the sharp end should engage further to inform the imaginations that currently guide policy. Simon Stevens identified the integration agenda as divisions in primary and specialist care, physical and mental health and health and social care. Does the NHS have enough divides to address already and why should we prioritise bridging the gap between frontline health care and those that seek to govern and improve it?

Earlier this year HSMC academics discovered some answers to this question when they visited Maastricht University to study primary care services. One of the most striking comparisons was the prominence of research within various primary care settings. In part, research integration was facilitated by close collaboration between Maastricht University and state of the art health and care facilities. Staff at Adelante Centre of Expertise in Rehabilitation and Audiology described job roles which combine frontline clinical work with dedicated time and resource for academic research into rehabilitation medicine.

Maastricht’s Living Lab in Ageing and Long-Term Care  has the specific mission of bringing together research, policy, education and practice – the blunt and sharp ends. Research questions are typically generated in the linked care homes, explored by university research teams and feed directly into legislation and training. An initiative to remove physical restraints piloted in the living lab’s care homes resulted in changes to national guidelines and inspectorate recommendations. This represents the potential for collaboration across the system to improve understandings of safety practices and quality of life.

Shamil Haroon (Institute of Applied Health Research, University of Birmingham) and Johcan Cals (CAPHRI School for Public Health and Primary Care, Maastricht University) recent BMJ piece from the same visit spotlights the higher proportion of Dutch GPs with PhDs compared to the UK. This intentional step to improve quality of GP services results from greater opportunities for research specialisation within GP training programmes. Interestingly Dutch GPs with PhDs didn’t leave practice to pursue academic careers. Instead they tended to use research skills to work on service improvement projects and development of guidelines. These findings demonstrate ways to close the gap between those who do the work and those who guide it and indicate how this can drive up care quality, including patient safety.

Braithwaite depicted health and care as a Complex Adaptive System. He argued that recognising this true nature of the system is the only way to break the cycle of repeating the same mistake – the false expectation that policy implementation will have a direct impact on safety outcomes. In the NHS the CAS is made up of a vast network of specialisms and sub-groups (e.g. professional groups, managers, patients), the behaviour of each adapts to its specific environment, so it is impossible to predict how the system will respond overall. No groups, even the senior leadership, have a complete understanding of the workings of their organisations, this restricts the scope for realising the aims of national policies. Assuming linear, rational responses to top down legislation would be a mistake.

This seems a logical, progressive argument implying that bottom-up safety initiatives may be more likely to work in health care organisations -an important consideration for leadership. With Braithwaite’s visit falling in the same week that Richard Thaler received the Nobel prize for behavioural economics, the unconforming nature of human decision-making seems a given. Doesn’t it?

But then what about the health care policies that have worked? None may have worked for everyone all of the time, but some have had greater success than others. Take public health, a field where CAS thinking is often applied, policies of flu vaccination, tobacco control, salt targets and fiscal interventions have had some success. These polices haven’t solved the complex health issues of older people’s care, cancer, heart disease or obesity, but there is enough evidence to see that they have played a role. They address part of the complexity and they do work, to some extent. This is perhaps where we see the limitations of CAS as an approach. Taken to the extreme viewpoint that top down policy can never work, it risks disregarding valuable evidence from evaluation about the nuances of health policy implementation.

Erik Hollnagel told a tale of two safeties. Safety I, the conventional approach, is the absence of unwanted consequences. Fear draws our focus towards the negative event and how to avoid it. In turn this reduces our ability to identify broader preventative factors. Safety II takes a wider view. A safety II approach in a health care organisation seeks to understand not just the adverse events, but the full spectrum of cases with positive outcomes.

Initiatives like Learning from Excellence (LfE) recognise that exploring the distinction between good and excellent care is just as valuable for avoiding harm as the more traditional focus on the good and bad care distinction. Initiated and led by clinicians and researchers in the West Midlands, in its basic form LfE is a reporting system where colleagues can relay their observations about excellent care to each other directly. A pilot study confirms that increasing awareness of excellent practice through positive reporting enhances clinical outcomes and morale. With the backing of West Midlands Academic Health Science Network LfE is just beginning to explore its potential to become embedded in organisations and expand to new methods and sectors.